NURSING RATIONALE DIAGNOSIS Preci Acute Pain related Predis Bulging eyeballs Lack of improper to physical Headache Exercise

se position disability in the Swelling while neck area AEB conjunctiva sleeping guarding behavior, Guarding irritability, verbal behavior report of pain and Irritability altered ability to antigen stimulus Reduced continue previous activates interaction with activities. monocytes and t people lymphocytes/t cells Verbal report of Definition: pain Unpleasant Immunoglobulin Altered ability sensory or antibodies form to continue emotional immune complexes previous experience arising with antigen activities from actual or potential tissue Phagocytosis Risk factors: damage or produces described in terms leukotrienes and Poor hygiene of such damage; prostaglandins sudden or slow Strength: onset of any Leukotrienes intensity from contribute to Strong family mild to severe inflammatory support with an anticipated process by end and duration anttracting WBC to of less than 6 the area; months. prostaglandins act as modifiers to inflammation Source:Nurses th Pocket Guide 12 Both produce Edition page. 586 enzymes such as

ASSESSMENT

DESIRED OUTCOMES After 4 days of nursing care, client will be able to:

NURSING INTERVENTION Independent:

JUSTIFICATION

EVALUATION After 8 hours of nursing care, client will be able to:

Report pain is relieved or controlled

Identify ways of avoiding or minimizing pain (e.g using firm mattress and proper supporting and good body mechanics)

To reduce the pain felt by the client

Goal met. Client was able to report pain is controlled.

Monitor skin color and vital signs

Skin color and vital signs are usually altered in acute pain To promote nonpharmacologic al pain management

Provide comfort measures (e.g repositioning, use of heat or cold packs, nurses presence and quite environment) Demonstrate nonpharmacologic al methods such as therapeutic touch, biofeedback and relaxation skill

Recognize nonpharmacologica l methods that provide relief

To reduce anxiety and fear of the patient to pain

Goal met. Client was able to recognize nonpharmacologi cal methods that provide relief
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collagenase Collagenase break down Pannus formation Erosion of articular cartilage Secondary degenerative changes in joint Mechanical stress on bone ends Stiffening of bone tissue Acute pain

Monitor use of self-administration or patient controlled analgesia for management of severe or persistent pain.

To distract attention and reduce tension

Demonstrate use of relaxation skills and diversional activities as indicated, for individual situation

Instruct in and encourage use of relaxation techniques such as focused breathing, imaging and listening to music etc.

Goal met. Client was able to demonstrate relaxation skills and diversional activities.

Source: Nursing Pocket Guide 12th Edition http://emedicine.medscape.com/article/791704-overview#a0104 22

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